Acceptance and hesitancy of parents to vaccinate children against coronavirus disease 2019 in Saudi Arabia

Background Vaccination of masses against coronavirus disease 2019 (COVID-19) is critical to overcome the pandemic and restore normalcy. However, vaccine refusal and hesitancy prevail in many countries. COVID-19 has rapidly spread in Saudi Arabia since 2020. The acceptance rate of COVID-19 vaccines has been investigated in adults aged >18 years in Saudi Arabia. This study aimed to understand the acceptance and hesitancy of parents to vaccinate children aged <12 years against COVID-19 in Saudi Arabia and identify strategies that can encourage their engagement. Methods We used an online cross-sectional survey distributed to parents who lived in all regions of Saudi Arabia to investigate parents’ views on the acceptability of a future COVID-19 vaccine for their children aged <12 years. Five hundred parents living in Saudi Arabia completed the survey. Results The survey indicated that mothers were more enthusiastic about participating in the study than fathers. The participant aged 37.31 ± 8.52 years. A total of 38.6% of participants refused to vaccinate their children. Additionally, 56% were unsure if the vaccine would cause serious side effects in children. A total of 48.8% of parents believed that the Pfizer vaccine was suitable for children, while 64.5% failed to decide whether to administer vaccines to their children. Conclusion Vaccine hesitancy remains a major problem worldwide. A lack of scientific evidence on vaccine efficacy, low education level, and reduced level of health education and promotion are the most common factors in parents in Saudi Arabia. However, some participants agreed to receive vaccines only to protect their family members, and due to governmental rules and school mandates. Therefore, vaccine efficacy and safety in children must be clearly communicated to the public. This information would aid in reducing the hesitancy of parents to vaccinate their children against COVID-19.

receive vaccines only to protect their family members, and due to governmental rules and school mandates. Therefore, vaccine efficacy and safety in children must be clearly communicated to the public. This information would aid in reducing the hesitancy of parents to vaccinate their children against COVID-19.

Introduction
The coronavirus disease 2019 (COVID-19) is a pandemic that has impacted millions of people [1]. Additionally, >195 million confirmed COVID-19 cases have been reported globally, including >6 million deaths. Therefore, vaccination of masses against COVID-19 is critical to overcome the pandemic and restore healthy living [2]. However, vaccine refusal and hesitancy are prevalent in many countries, and vaccines are still unavailable for children aged <12 years. Additionally, parents are concerned about children's well-being, and convincing them for vaccination is a complex process [1].
Vaccine acceptance is complicated and context-specific, varying with the place, time, social class, and community [3][4][5][6][7]. A study in Europe showed that vaccine hesitancy is mainly influenced by safety concerns and adverse effects of vaccination [8]. Another study demonstrated that many healthcare workers in Ireland avoided the seasonal influenza vaccination due to misconceptions and a lack of trust in the vaccine [9,10].
Since October 17, 2020, COVID-19 has rapidly spread in Saudi Arabia, causing >750,000 cases and 9,000 deaths. The current population of Saudi Arabia is 35,389,457, and >10,000,000 individuals are aged <18 years. A previous study that investigated the rate of acceptance of COVID-19 vaccines observed that only 48% of Saudi adults aged >18 years intended to receive vaccines [2]. These results are also consistent with the total number of Saudi residents who got vaccinated (approximately 50%). However, studies have neither investigated the acceptance rate of COVID-19 vaccines and their determinants in people aged <18 years nor determined the predictors associated with Saudi parents' intent to vaccinate children when vaccines are available for children aged <12 years. Therefore, this study aimed to understand the acceptance and hesitancy of parents to vaccinate their children against COVID-19 in Saudi Arabia, and identify strategies that can help encourage their engagement.

Study design
A cross-sectional study was conducted between August 2021 and February 2022.

Study setting and participants
A web-based survey was conducted with parents who lived in all regions of Saudi Arabia, including western, southern, northern, eastern, and central regions.

Sampling and procedure
We performed convenience and snowball sampling. We calculated the sample size by epi-info software version 7. So, a sample size of 385 participants would help achieve a 95% confidence interval (CI) and 5% margin of error. To raise the external validity and generalizability of the study, the sample size was raised to 500 participants. An online survey on Google Forms was distributed to parents in Saudi Arabia through social media platforms including emails, and they were requested to circulate the forms to other parents as well.

Outcome
The rate of acceptance of parents to vaccinate their children.

Data collection tool
The questionnaire was self-administered with both Arabic and English versions to allow participants to choose the appropriate language was conducted. The participants were invited to complete an online survey on Google Forms, along with their ethical consent to participate in the study. Opinion on whether vaccines protect children from COVID-19, whether vaccines strengthen the immune system, and whether they would recommend vaccines to other parents. 2.7.5. Acceptance of vaccination of child/children. The parents' answers were recorded on a 3-points Likert scale as: "disagree, agree, and undecided." 2.7.6. Factors affecting vaccine acceptance. Concerns on vaccinating child/children against COVID-19, safety concerns of the vaccine, source of information on vaccines, concerns on serious reaction to vaccines, whether child/children had serious reaction/reactions to previous vaccinations, and whether parents think that vaccines are suitable for children only if vaccine benefits are larger than their risks, along with easy availability of vaccines.
The questionnaire was adapted from previous studies [11][12][13]. The original questionnaire in English was bidirectional "back-back" translated into Arabic. Both versions were available for participants. We used the most appropriate and understandable terms and got them revised by three experts. A pilot study was conducted to test the questionnaire on 20 participants to confirm all the language amendments and ease of use and determine the feasibility of the survey. Additionally, we tested the participants' responses to different items of the questionnaire. The validity was estimated based on whether the questions were comprehensive. Data of the pilot study were excluded from the final analysis.

Statistical analysis
Data entry and statistical analysis were performed using the Statistical Package for Social Science (SPSS) software version 22. Descriptive statistics are presented as tables and graphs. The Student's t-test was used to evaluate quantitative normally distributed variables, and the Mann Whitney U test to evaluate non-normally distributed variables. The Chi-square test was used for qualitative variables. Regression analyses were performed to assess the determinants of acceptance. A p<0.05 was considered to be statistically significant.

Results
As indicated in Table 1, 77.8% of the participants are mothers, 78.6% are Saudi residents, and 41.4% are residing in Makkah region. The participants' mean age was 37.31 ± 8.52 years, and 91% were married. A total of 56.6% had a bachelor's degree, and 56% were working. The mean number of children was 2.84 ± 1.51, and 59.6% of the participants had children aged <12 years.   We analyzed the attitude of participants towards vaccines. As indicated in Table 2, 29.6% of the participants are concerned about their children acquiring COVID-19, 57.8% believe that vaccines would strengthen the immune system, 50.2% believe that vaccine benefits are greater than its risk, and only 36% believe that vaccines would protect children from COVID-19. The most common reason for vaccinating the children was the school mandate. A total of 38.4% of the participants believe that COVID-19 vaccines would be moderately safe for children. However, 56% were unsure on whether vaccines would cause serious side effects in children.
Further, healthcare workers provided information on COVID-19 vaccines to 31.8% of the participants (Table 2). Additionally, 48.8% of the parents believed that Pfizer vaccine was suitable for children; but, 51.2% do not believe that vaccines would be available easily. Furthermore, 48.8% of the participants would recommend others to vaccinate their children.
A total of 45.4% of the participants or someone in their family were previously diagnosed with COVID-19 (Table 3). Among them, 23.4% did not require any medical support, while 86% lost a family member due to COVID-19.
As indicated in Table 4, factors that influenced COVID-19 vaccination in children were as follows: (a) being mother: 71.3% of the participants who vaccinated their children were mothers; (b) the mean of age of participants who vaccinated (39.10 ± 9.714 years) children was higher than those who did not (34.86 ± 6.839) vaccinate their children; (c) marital status: 89.3% of the participants who vaccinated children were married; (d) educational level: the most common education in the two groups was bachelor's degree; and (e) employment: 60.2% of the participants who vaccinated children were working. Moreover, the number of children and their ages were significant factors that affected vaccination of children. Awareness of any child with serious reaction due to vaccine that required medical aid was significantly lower in parents who vaccinated (12.1%) than in those who did not vaccinate (24.6%) their children. Further, 62.6% of the participants who vaccinated their children believed that the Pfizer vaccine was the most suitable for children, while 64.5% of the participants who did not vaccinate their children could not decide on the suitability of vaccines. A higher proportion of participants (94.1%) who vaccinated children believed that vaccines would be easily available than those who did not vaccinate children (82.5%) (p<0.05).
Next, we performed logistic regression analysis of predictors that influenced COVID-19 vaccination of children.

Discussion
COVID-19, caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2), is an emerging pandemic since its first clinical observation in December 2019 in Wuhan, China [13]. The pandemic has led to loss of life in many age groups along with extensive family disruption and social distancing [15]. With limited therapeutic options for COVID-19, vaccine development has been boosted worldwide [1]. COVID-19 vaccines are major public healthcare achievement of the 21 st century, and vaccines have apparently decreased the disease severity and progression [15]. Nevertheless, the success of COVID-19 vaccines depends on achieving herd immunity.
People's unwillingness to receive vaccines has been categorized as "vaccine hesitancy." Several studies have studied the causes of such hesitancy in various populations. The present survey focused on the rate of acceptance of COVID-19 vaccines in 500 parents from different families in Saudi Arabia. We compared the results of the present study with that of a Turkish study comprising 428 participants and an English study comprising 1,252 participants [11,13]. The mean age of participants in all the three studies ranged between 30 and 40 years [11,13]. The present study found that mothers were significantly more enthusiastic for participating in the study than fathers. This result is similar to that reported by Yigit [14]. The main reasons for this acceptance were protection of children from COVID-19 complications and protection of families who were at high risk of acquiring COVID-19. In the current study, 38.6% of the parents denied vaccinating their children, but >50% of the participants agreed to vaccinate children. The findings suggest that the most common motive for vaccinating the children was school attendance. Less than 40% of the participants believed that vaccines were protective. Nevertheless, 89% of the parents believed that vaccines were acceptable, yet <50% were hesitant to vaccinate their children. In the study by Yigit et al., the most important reason for vaccine compliance was the willingness to protect patients with chronic diseases living together in the same house [13]. The motive in the present study was similar with a major factor for vaccinations was protecting a family member from another relative diagnosed with COVID-19.  Vaccine hesitancy is the most significant barrier to vaccine acceptance worldwide. The hesitancy is linked to certain factors, such as vaccination history, side effects, safety and efficacy, lack of confidence in the healthcare system, and whether the government provided vaccine gratuitously [15]. Some participants (<50%) in the present study believed that vaccines may not strengthen the immune system. This could be attributed to a lack of knowledge on vaccine importance in the parents or lack of scientific evidence on the efficacy of the vaccines. Nevertheless, some parents (50%) believed that certain types of vaccines were more beneficial and had greater benefits than risks. This finding explains the preferential selection of the Pfizer vaccine by parents in the present study. The study by Bell et al. suggested that the main reason for vaccine hesitancy was insufficiency of scientific evidence to support vaccination. However, 62% of the participants were concerned about vaccine safety [11]. Therefore, educating the population with scientific evidence would convince them on the vaccines and reduce uncertainty. Additionally, parents may tend to be more protective about their children than  [13]. In the current study, approximately 56% of the parents were educated; and, 86% lost a family member, that inspired them to undergo vaccination. Therefore, the education level is the most common factor influencing the parental decision on children's vaccination. Yigit et al. suggested that the side effects of vaccines was the main reason for the unwillingness of participants to vaccinate their family against COVID-19, while 9% of participants failed to believe in the effectiveness of vaccines. Moreover, <1% believed that vaccines may contain cellular microchips [13]. This false belief emphasizes the lack of scientific knowledge about the vaccine's effects on the body. The study by Bell et al. indicated that 3% of the participants vaccinated their children only to avoid social distancing and attain normal lives [11]. The remaining participants are vaccine hesitant. These results are slightly different from those of the present study that suggested that the main reason for vaccine hesitancy was the lack of scientific evidence on vaccine efficacy. Goldman et al. highlighted similar reasons for vaccine hesitancy-the questionable novelty of the vaccine [1].
The study had inherent limitations, as the study used an electronic survey platform which was useful for data collection, this limited the study's ability to define and describe the population. In addition, the sample size was convenient with biased respondents.
In conclusion, vaccine hesitancy remains a major problem worldwide. Therefore, it is crucial to understand and address factors that may affect COVID-19 vaccine acceptability in parents to prevent vaccine inequalities. The most common factors were a lack of scientific evidence on vaccine efficacy, low education level, and reduced level of health education and promotion. However, some populations undergo vaccination only to protect their family members, due to governmental rules, and for school attendance. Additionally, information on different approaches for COVID-19 vaccination, including vaccine efficacy and safety in children, must be clearly communicated to the public. This information would aid in reducing the hesitancy of parents to vaccinate their children against COVID-19.